OPEN SEASON Airway management devices such as video laryngoscopes and supraglottic devices improve with each generation.

In his 31 years of anesthetizing patients, anesthesiologist Thomas Durick, MD, has seen plenty of airways that "would make the hair on the back of your neck stand up." He recalls a recent case at Fremont (Calif.) Surgery Center during which he successfully navigated a difficult airway using a video laryngoscope with a camera at the tip of the blade and a monitor to provide him with direct views of the glottis. "I was almost chuckling to myself as I was doing it, and someone in the OR asked me what was so funny," he says. "I'm an old-school guy, so I just couldn't explain how much of a difference [the technology] made, how easy it was, comparatively. You almost feel like you're cheating."

Anesthesia practitioners like Dr. Durick have several effective options at their disposal when it comes to making even the most problematic airway a little less hair-raising.

Video laryngoscopes. Being able to reach for a video laryngoscope when caring for an obese patient with a recessed mandible, a small oral opening and a large neck that prevents an effective evaluation of the anatomy has been the "the biggest game-changer" in airway management, says Dr. Durick. He touts the technology's ease of use and rapid learning curve, and says the devices continue to improve, thanks to larger higher-definition displays, anti-fog capabilities and smarter screen placement.

Although a premium video laryngoscope can cost more than $10,000, the number of low-cost, single-use options has multiplied in recent years, according to Rick Novak, MD, an anesthesiologist at Waverley Surgery Center in Palo Alto, Calif. Dr. Novak travels to as many as 8 different surgery centers, some of which don't have video laryngoscopes, so he always keeps a disposable model in his briefcase.

"I had a case just last week where I couldn't see the patient's larynx with a regular scope, so I placed a video laryngoscope in her mouth, visualized the larynx and intubated the patient with no problem," he says. "You just throw the disposable video laryngoscope away afterward. Each device costs about $100, and after I use one, I go back to my office and put another one in my briefcase."

Dr. Novak may be fond of the enhanced visual capabilities video laryngoscopy provides, but he cautions against getting too reliant on the technology. "Knowing how to use a traditional metal laryngoscope is a skill we all have to develop," he says. "I'd say 95% of the time, direct laryngoscopy is easy to do with a Miller 2 blade, and there's really no cost to it."

Dr. Novak's reusable video laryngoscope of choice costs about $13,000, a price he considers a relative bargain compared to the alternative.

"Spending $13,000 for a quality video laryngoscope is significantly less expensive than the cost of a lawsuit you'd have to settle for $10 million for a patient who died or suffered permanent brain damage because you lost an airway," he says. "Why would you want to risk that for $13,000?"

Supraglottic airway devices. Anesthesia practitioners have multiple options when it comes to supraglottic devices, and many deserve a try, says Dr. Durick. In particular, he says, the inflatable supraglottic airway device has "changed the landscape." He has also seen a rise in the popularity of non-inflatable supraglottic devices, which have the potential to be kinder to the patient's airway.

"There's a learning curve with inflatable devices, so you can overinflate them if you're not careful," he says. "We once had 2 patients come into the ER with acute epiglottitis one day apart, and it turns out both had had surgery during which the same anesthesia provider used a supraglottic airway. We had to intubate both patients, because the epiglottis was so swollen it obstructed their airways. There were distinct marks on the epiglottis where the supraglottic airway had bent it back and cut off the blood supply."

BACKUP PLAN
The ABC(&Ds) of Airway Management

STEP BY STEP A "cascade" airway management plans starts with the simplest and safest option.

In his role as an adjunct clinical associate professor of anesthesia at Stanford University, Rick Novak, MD, teaches a slight adjustment to one of medicine's most enduring mnemonics. "In critical care medicine, you focus on ABC — airway, breathing, circulation," says Dr. Novak. "I teach the importance of the mnemonic airway, airway, airway. You simply can't afford to lose a patient's airway. In a 'can't-intubate, can't-ventilate' scenario, you have 5 minutes to oxygenate the patient before there's a very real risk of permanent brain damage."

This is why Dr. Novak considers bag-mask ventilation the most vital airway skill. Even in patients who have unexpectedly difficult intubations, mask ventilation can keep the patient oxygenated while the anesthesiologist determines the best option to proceed.

"You need a plan," he says. Or, in his case, the 4 plans — A, B, C and D — included in the system first proposed by C. Philip Larson Jr., MD, professor emeritus at Stanford University and one of Dr. Novak's past professors and mentors in the area of airway management.

Dr. Larson's "A through D" system serves as a "cascading recipe" for avoiding airway disasters:

• Plan A: Employ direct laryngoscopy using a Miller or Macintosh blade.
• Plan B: Use a video laryngoscope to secure the airway.
• Plan C: Intubate through a supraglottic airway using a fiber-optic bronchoscope.
• Plan D: Stop the anesthetic, wake the patient and reschedule the case for another day when awake fiber-optic intubation would be used. If the operation cannot be postponed, perform a tracheostomy.

"The simplest, safest option that works is the preferred method for maintaining an airway," says Dr. Novak. "That's why the cascade is so practical."

— Bill Donahue

Ready for anything
Video laryngoscopes and supraglottic devices have become the standard of care in airway management — and the technology gets better with each generation.

"They're every bit as important to an anesthesiologist as an arthroscope is to an orthopedic surgeon or a laparoscope is to a general surgeon," says Dr. Durick. "Most of these options cost less than $4,000 apiece. [Investing in one] is an absolute no-brainer."

But even high-end airway devices won't make up for a practitioner who lacks the confidence and respect the job demands. No matter how capable or advanced the tools are for establishing an airway, they're no replacement for informed instincts, good judgment and preparedness. Dr. Durick's advice for any provider: Take the proper precautions so you're able to respond to any event, within reason, in case something goes awry.

Airway tools are no replacement for informed instincts, good judgment and preparedness.

Dr. Durick says a good provider never blames his tools. "If there's a problem with an airway, it's probably because I chose the wrong-size airway device based on the patient's height and weight or because it's not seated properly," he explains. "Maybe there's reactive airway disease, or maybe the patient has gone into laryngospasm or bronchospasm. That's why you diagnose quickly and always have a backup plan."

If your anesthesia providers lack the skill or experience to use a particular airway device or technique, they need to develop that skill with help from fellow clinicians or even manufacturer reps, suggests Dr. Durick. He says providers never know when they'll need to put the tools to use in a life-or-death situation and can't hesitate when the stakes are highest.

"The airways you expect to be normal, but are not — those are the ones that are the scariest," he adds. "Providers have to know where their tools are, and know how and when to use them, because they're the last line of defense against an airway disaster." OSM